13. Diseases of the Salivary glands. Sjogren Syndrome. Tumors of the Salivary Glands.

Question 1

What is the GENERAL ANATOMY of the Salivary Glands?

Answer 1

Consists of 3 MAJOR PAIRS
1) Parotid (Serous)
2) Submandibular (Mucoserous)
3) Sublingual (Mucoserous)

MINOR
a. Labial
b. Lingual
c. Palatal
d. Paryngeal
e. Nasal

Question 2

1| Describe the PAROTID GLAND

Answer 2

• BTW the Mandibule AND Mastoid , Subcutaneous Muscle AND Digastric

0 Histology = Fibrous Pseudocapsule

• When there’s PAIN, it’s POORLY Distendable
• Tumours / Inflammation of it will spread towards PARAPHARYNGEAL / PTERYGOPALATINE FOSSA
• Has the STENSEN’S DUCT = 6cm, which loops over / around the MASSETER and is OPPOSITE to 2nd Upper Molar

0 INNERVATION = CN 7 in Lateral / Deep Lobe
- Temporal / Zygomatic / Buccal / Marginal Mandibular AND Cervical Branches

0 LYMPH DRAINAGE
- Peri-glandular LN
- Submandibular LN
- Deep Neck

Question 3

2| Describe the SUBMANDIBULAR GLAND

Answer 3

• BTW the Mandibule AND Digastric
• Turns AROUND the Mylohyoid
• Connects TO Sublingual Gland AND Posterior Floor of Mouth
• Has WARTON’S DUCT = 5cm and runs in SUBLINGUAL PLANE BENEATH the mucosa; CROSSES OVER the Lingual Nerve; OPENS IN Sublingual CARUNCLE

0 INNERVATION = Lingual / Hypoglossal Nerves

0 BLOOD SUPPLY = Facial Artery / Vein

0 LYMPH DRAINAGE
- Lateral LN
- Posteroinferior LN

Question 4

What is the CLINICAL EXAMINATION of the Salivary Glands?

Answer 4

1) HISTORY
- Systemic Disease
- Medications
- Previous Diseases, Tx, Surgeries

2) INSPECTION
- External AND CN 7
- Intra-oral AND Tonsillar Regions

3) PALPATION
- Parotid gland (BARELY Palpable)
- Submandibular gland
- Sublingual gland

Question 5

What are the IMAGING STUDIES for Salivary Glands?

Answer 5

0 1st Line = Ultrasound

1) SQUAMOUS CELL CANCER
- Isoechoic
- Slightly Heterogenous
- w/ Calcification
- w/ Acoustic Shadowing

2) ADENOCARCINOMA
- Hypoechoic
- Ill-defined
- NO acoustic enhancement

3) PLEOMORPHIC ADENOMA
- Heterogenous Structure
- With enhancement
- NO Necrosis / Calcification

4) WARTHIN TUMOR
- Well-defined w/ LARGE Fluid Areas
- With enhancement
———————————————————————
0 X-RAY = For Stones only

0 CT / MRI = Tumors

Question 6

What are the IMAGING STUDIES for Salivary Glands?

Answer 6

0 1st Line = Ultrasound

1) SQUAMOUS CELL CANCER
- Isoechoic
- Slightly Heterogenous
- w/ Calcification
- w/ Acoustic Shadowing

2) ADENOCARCINOMA
- Hypoechoic
- Ill-defined
- NO acoustic enhancement

3) PLEOMORPHIC ADENOMA
- Heterogenous Structure
- With enhancement
- NO Necrosis / Calcification

4) WARTHIN TUMOR
- Well-defined w/ LARGE Fluid Areas
- With enhancement
———————————————————————
0 X-RAY = For Stones only

0 CT / MRI = Tumors

Question 7

What is the BIOPSY for the Salivary Glands?

Answer 7

INCISIONAL BIOPSY

• For CHRONIC Inflammation
• NOT FOR Benign
• Used for ULCERATIVE MALIGNANT

Question 8

What are NON-INFLAMMATORY DISEASES of the Salivary Glands?

Answer 8

1) Sialolythiasis

2) Sialadenosis

3) Raula

Question 9

What is SIALOLITHIASIS? (Non-Inflam.)

Answer 9

• AKA Salivary Stones
• Causing OBSTRUCTION of Salivary DUCT
• Major Cause for Unilateral Parotid / Subman Gland Swelling

0 DUE to
- Hypercalcemia
- Xerostomic Meds
- Smoking

0 TREATMENT
- External Lithotripsy
- Interventional Sialendoscopy

Question 10

What is SIALADENOSIS? (Non-Inflam.)

Answer 10

• Symmetric swelling of Major Glands (Parotid)

0 DUE to
- Alcoholism
- Vitamin Deficiencies
- Diabetes
- Anorexia
- Protein Deficiency

0 PATHOLOGY = LARGE Acinar Cells

Question 11

What is RAULA? (Non-Inflam.)

Answer 11

• A CYST of the Mouth Floor
• 2 TYPES
  a. Real Cyst = Retention of Saliva
  b. Pseudocyst = Saliva Extravasation
• Congenital / Acquired

0 TREATMENT
- Spontaneous Drainage
- Aspiration
- Excision of SUBLINGUAL Gland

Question 12

What are INFLAMMATORY DISEASES of the Salivary Glands?

Answer 12

1) Epidemic Parotitis / Mumps

2) Acute Suppurative Sialadenitis

3) Juvenile Recurrent Parotitis

Question 13

What is EPIDEMIC PAROTITIS? (Inflam.)

Answer 13

• Caused by PARAMYXOVIRUS

0 SYMPTOMS
- Fever
- Swelling = acute, painful
- Hamster Cheeks
- Reddened Orifices

0 Treatment = Supportive
0 Prophylaxis = Vaccination

Question 14

What is ACUTE SUPPURATIVE SIALADENITIS? (Inflam.)

Answer 14

0 DUE to,
- Staphylococci
- Streptococci
- Haemophilius
- Anaerobes

0 PATHOPHYSIOLOGY = ASCENDING INFX in DECREASE Salivary Flow

0 SYMPTOMS
- Unilateral, Diffuse, Painful Swelling
- Reddened Orifice

0 COMPLICATIONS = Abscess Formation

0 TREATMENT
- Antibiotics
- Analgesics
- Anti-Inflammatory

• Incision / Drainage PARALLEL to CN 7, IF Abscess!

Question 15

What is JUVENILE RECURRENT PAROTITIS? (Inflam.)

Answer 15

• Occurs in Children
• UNKNOWN Etiology / Pathogenesis

0 SYMPTOMS
- Asymmetric Swelling
- Painful
- Saliva may be PURULENT
- Trismus

0 DIAGNOSIS = Leaf-Tree appearance in Sialography

0 TREATMENT = Antibiotics

Question 16

What is SJOGREN SYNDROME?

Answer 16

• Autoimmune Disease of Salivary / Lacrimal Glands
• Bilateral Parotid ENLARGEMENT
• Occurs in 50 / 60 yo

0 SYMPTOMS
- Dry eyes / mouth
- Joint pain
- Skin rashes
- Dry cough

0 DIAGNOSIS
- Anaemia, ERS Elevation, Eosinophilia
- Presence of Anti-Nuclear Abs (anti-SSA/Ro)
- Presence of Rheumatoid Factor (RF)

0 BIOPSY
- Parenchymal Hypertrophy
- Islands of Myoepithelial Cells

0 TREATMENT
- Immunosuppressants
- Supportive Tx = Aritificial Saliva / Tears

Question 17

What are the TUMORS of the Salivary Glands?

Answer 17

1) PLEOMORPHIC ADENOMA
- MOST Common!
- Slow growing, painless
- Smooth, Solid
- NO True Capsule
- Tx = COMPLETE SURGICAL Excision

2) WARTHIN’S TUMOR
- Makes up 6 - 10% of Parotid Gland Tumors
- Affects OLDER Caucasian Males
- Slow growing, painless
- Encapsulated
- Smooth
- Cystic Spaces

3) ONCOCYTOMA
- RARE!
- Rapid enlarging
- Painless
- Encapsulated
- Homogenous, Orange

4) MUCOEPIDERMOID CARCINOMA
- MOST COMMON Malignancy!
- Low Grade = slow growing, painless (WI
- High Grade = rapid enlarging, painful
- Well-circumscribed / encapsulated
- Solid w/ Cystic Spaces

• Tx = WIDE LOCAL Excision (Low) / RADICAL Excision (High)